Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Star Manor during CMS and state inspections, most recent first.
A resident with dementia, repeated falls, and strict hip precautions was assisted by an RN to the bathroom with a walker despite a care plan that said nursing staff were not to ambulate her. During the transfer, staff heard a popping sound from the hip, and the resident later developed swelling and increased pain; hospital evaluation confirmed a dislocated right hip prosthesis requiring closed reduction. Records and interviews showed the resident had poor safety awareness, self-transferred repeatedly, and required close supervision, alarms, and TTWB/30-lb weight-bearing restrictions.
A resident with dementia, fractures, anemia, impaired mobility, and high fall risk had repeated self-transfers and falls, but the care plan did not include key interventions staff were using, including a chair/tab alarm and direction to keep the resident out of her room. Staff interviews showed the resident was impulsive, required close monitoring, and was sometimes found self-transferring or moving independently in her wheelchair, while the chair alarm was at times not attached to the resident. The DON stated the alarm should have been added to the care plan so staff would know how to provide care.
A resident with multiple psychiatric and medical diagnoses received repeated PRN Lorazepam orders for anxiety without documented clinical rationale for continued use, despite facility policy requiring such documentation for psychotropic medications beyond 14 days. The DON was unaware of this requirement, and a physician-signed form for dose reduction attempts was left incomplete.
The facility failed to accurately submit RN hours on the PBJ, potentially affecting all 30 residents. The PBJ report indicated no RN hours on certain days, but payroll and schedules showed RNs worked 8-hour shifts on those days. The administrator confirmed the scheduling and was unsure of the report's inaccuracy, requiring further investigation.
The facility failed to ensure proper infection control practices in the laundry department, as staff sorted soiled laundry without using appropriate PPE, such as gowns, which could lead to contamination of uniforms. The infection control preventionist and DON were unaware of this practice, despite the facility's policy requiring protective equipment when handling soiled laundry.
Failure to Follow Mobility Restrictions and Supervision Needs During Bathroom Transfer
Penalty
Summary
The facility failed to provide care and supervision consistent with a resident’s needs, orders, and care plan to prevent an accident during care for a resident with severe cognitive impairment, multiple recent falls, strict posterior hip precautions, and a right lower extremity weight-bearing restriction. The resident’s records showed dementia, poor judgment, poor safety awareness, inability to ambulate with nursing staff, and a care plan directing staff not to ambulate the resident and to use close supervision, alarms, and assistance for transfers. The resident also had a history of repeated falls at the facility and was identified as high risk for falls. On the morning of the incident, an RN was aware of the resident’s mobility restrictions but assisted her to the bathroom with a walker rather than using the wheelchair. During that ambulation, a popping sound was heard from the right hip area. The resident later had increased pain and swelling of the right leg, and the leg was described as appearing larger and warm to the touch. The resident was sent for emergency evaluation and was found to have a dislocated right hip prosthesis, requiring a closed reduction at the hospital. The record also showed multiple prior episodes of unsafe self-transfer and ambulation, including being found on the floor, walking independently in the hallway, and chair or bed alarms not being connected or not functioning properly. Therapy and physician documentation reflected that the resident required TTWB or 30-pound weight bearing with posterior hip precautions, and that ambulation with nursing staff was not safe. Facility interviews confirmed staff knew the resident had dementia, was impulsive, and was not to be walked by nursing staff, yet on the incident date the RN chose to ambulate her to the bathroom because the walker was closer than the wheelchair and the resident was already standing and unable to wait.
Care Plan Not Updated for High-Fall-Risk Resident
Penalty
Summary
The facility failed to update and implement the care plan for a resident with severely impaired cognition, dementia, anxiety, fractures, anemia, and high fall risk. The resident required extensive assistance with transfers and toileting, used a manual wheelchair, and had a bed alarm in use. A fall risk assessment identified the resident as high risk for falls, with clinical suggestions including nonskid footwear, a toileting program, and personal or pressure sensor alarms. The resident’s care plan included a silent bed alarm, call light use, fall mat, low bed, and assistance to the recliner in the common area for comfort and positioning, but it did not include a tab alarm, direction to keep the resident out of her room, or the recliner in the common area as a behavior-management intervention. Staff interviews showed the resident had dementia, was impulsive, self-transferred, and was not to be left alone in her room. Multiple staff stated the resident used bed and chair alarms and was parked in the commons area for close observation, and that staff were expected to follow the care plan and/or Kardex. One nurse stated the chair tabs alarm was not included on the care plan and should have been, while another nurse stated the chair alarm was not attached to the resident and had been clipped to the wheelchair instead. A nursing assistant stated she had forgotten to attach the chair alarm to the resident on one occasion. Other staff described repeated self-transfers, including from the wheelchair and bed, and noted the resident had fallen after self-transferring. The director of nursing stated staff were expected to follow the care plan and that once the chair tabs alarm was in place it should have been added to the care plan within one hour so staff would know how to provide care. The DON also stated the chair tabs alarm should have been placed on the resident’s back, out of reach, with the string shortened. Facility policy required an individualized comprehensive care plan and updates when there was a significant change in condition, when the desired outcome was not met, and at least quarterly, and stated all staff were required to review, understand, and follow each resident’s current care plan.
Lack of Clinical Rationale for Continued PRN Lorazepam Use
Penalty
Summary
The facility failed to ensure that a clinician documented a clinical rationale for the continued use of a PRN (as needed) psychotropic medication, specifically Lorazepam, for a resident with diagnoses including depression, psychotic disorder with delusions, pain, weakness, anxiety, and Alzheimer's disease. Multiple verbal orders for Lorazepam 0.5 mg every eight hours as needed for anxiety were confirmed and renewed over several months, but none of the orders included a documented clinical rationale for the ongoing use of the PRN medication. Additionally, a facility form regarding psychotropic medication gradual dose reduction attempts indicated that a dose reduction was not possible, but the required section for clinical rationale was left blank and only signed by the physician. During an interview, the DON acknowledged that the facility had implemented a process for providers to write new orders for PRN medications that were expiring but was unaware that a clinical rationale was required for the continued use of PRN psychotropic medications. Facility policy stated that PRN orders for psychotropic medications beyond 14 days required practitioner documentation of the rationale for the extended order, which was not followed in this case.
Inaccurate RN Hours Submission in PBJ
Penalty
Summary
The facility failed to ensure that registered nurse (RN) hours were accurately submitted on the payroll-based journal (PBJ), which had the potential to affect all 30 residents residing in the facility. The PBJ Staffing Report CASPER Report 1705D for the fiscal year Quarter 2 2024 identified a trigger for no RN hours on specific days, including 2/24, 3/9, 3/10, 3/17, 3/24, and 3/31. However, upon review of the facility's payroll and working schedule, it was found that an RN was working for 8 hours consecutively on all six days identified in the PBJ report. During an interview on 6/27/24, the administrator confirmed that RNs were scheduled per the requirements on the identified days and expressed uncertainty about why the PBJ report was inaccurate. The administrator indicated a need to investigate further to identify the reason for the discrepancy.
Inadequate Use of PPE in Laundry Sorting
Penalty
Summary
The facility failed to ensure that soiled and potentially contaminated laundry was sorted in a manner that reduced the risk of cross-contamination and the spread of infection. During a laundry tour, it was observed that dirty laundry from the nursing floor was brought to the laundry room in barrels and sorted into different carts without the use of appropriate personal protective equipment (PPE). The housekeeper responsible for sorting the laundry wore gloves but did not wear a disposable gown, which could lead to contamination of her uniform. The facility's policy required the use of protective gloves and other equipment as needed when handling soiled laundry, but this was not being followed. Interviews with the infection control preventionist and the director of nursing revealed that they were unaware that laundry staff were not using PPE while sorting soiled laundry. Both acknowledged that the lack of PPE use was an infection control issue, as it posed a risk of contaminating staff uniforms. The facility's policy on handling soiled laundry, dated 7/25/23, specified the need for protective equipment, but this was not being adhered to, leading to a deficiency in infection prevention and control practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Senior Living On Columbia | 23.9 mi | ★★★★★ | 1 | 0 |
| Woodside Village | 24.9 mi | ★★★★★ | 5 | 0 |
| Oakland Park Communities, Inc. | 28 mi | ★★★★★ | 19 | 0 |
| Thief River Care Center | 28.1 mi | ★★★★★ | 12 | 1 |
| Karlstad Healthcare Center Inc | 28.8 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.